Campbell BPH/LUTS Medical Management 2021 Flashcards
Frequency volume charts should be used during basic evaluation of ___ or ___.
Prevalent storage LUTS or nocturia
** FVCs = mainstay for assessment of nocturia
Nocturia definition
The complaint that an individual has to wake at night one or more times to void.
FVC duration: ___
3 days
Urine dipstick test and/or urine microscopy is suggested in ___.
Urine cytology should always be requested in men with ___, especially if they have ___.
All patients complaining of LUTS.
Severe storage symptoms and dysuria
A smoking history
The value of PSA testing i patients with LUTS (3):
Assess the risk and eventually rule out the presence of PCa
Estimate PV
Predict BPH-related outcomes
When to measure PSA: ___
Exception: ___
Measure PSA if diagnosis of PCa will change management.
Exception: life expectancy < 10 years
PSA level where PV would be > 40 mL in these ages:
50s: ___
60s: ___
70s: ___
PSA level at PV > 40 mL, at age ranges:
50s: 1.6 ng/mL
60s: 2.0 ng/mL
70s: 2.3 ng/mL
** Also cited in EAU guidelines
According to Guess et al., (1993), serum PSA level is reduced by 40-50% after ___ months of 5ARIs.
12 months
p. 3345
TRUE or FALSE:
GFR should be assessed routinely in patients with LUTS.
FALSE.
Serum creatinine may be assessed if renal impairment is suspected based on medical history or if surgical treatment is considered.
MTOPS: <1% of men with LUTS experienced kidney failure over a period of 4 years.
PVR volume regarded as important: > ___ mL
< ___ mL is considered nonsignificant
> 50 mL = important
< 30 mL = nonsignificant
- Ultrasound should be used to assess PVR volume
- Abnormal PVR NOT highly correlated with BOO (can also be DUA)
PVR volume should be assessed during ___.
During basic workup and follow-up of patients with LUTS
** Monitor PVR closely if patient chooses nonsurgical therapy.
Uroflowmetry main parameters
Qmax (peak urinary flow rate/PFR)
Voided volume
Flow pattern
PFR cutoff ___ could be used to define BOO, but does NOT differentiate between obstruction and bladder decompensation.
15 mL/s
** Uroflowmetry is optional in LUTS, but recommended before any active treatment.
The gold standard for assessment of LUTS pathophysiology.
Characterized by 2 evaluations: ___ and ___
Invasive urodynamic test
Filling cystometry and PFS
** It is used to identify DO, DUA, low bladder compliance, and BOO
Cystometry assesses the ___ phase, detects ___.
Storage phase
Involuntary detrusor contractions, which may identify DO.
** DO = may benefit from anticholinergic drugs alone or in combination
PFS assesses the ___ phase.
Differentiate: BOO and DUA based on flow rate and detrusor pressure
Voiding phase
Detrusor pressure and flow rate
BOO = impaired flow rate with increased detrusor pressure DUA = impaired BOTH flow rate and detrusor pressure
Urodynamics NOT recommended routinely for LUTS, except in these specific scenarios: (5)
- Previously unsuccessful invasive treatments for LUTS
- Cannot void more than 150 mL
- PVR volume greater than 300 mL
- > 80 years of age with predominantly voiding
LUTS - <50 years of age with predominantly
voiding LUTS
ALSO: PFS for patients with Qmax >10mL/s before surgical treatment is considered
TRUE or FALSE
Routine upper tract ultrasonography is recommended in patients with LUTS.
FALSE.
** Imaging assessment of the upper tract is currently suggested for patients with LUTS combined with an elevated serum creatinine level or large PVR volumes.
ALSO: History of hematuria, UTI, urolithiasis, or prior urinary tract surgery
Prostate volume should be assessed by TRUS/suprapubic before: ___ or ___
5ARI treatment
OR
BPH surgery (to choose most appropriate technique)
Cystourethrogram is suggested for: ___
Additional diagnostic test when urethral strictures or bladder anomalies are suspected.
TRUE or FALSE
Cystourethroscopy is useful for the diagnosis of BOO and to determine the need for treatment.
FALSE.
A poor correlation between BOO and cystourethroscopy findings has been widely reported.
USE FOR: gross hematuria, bladder CA, recurrent UTIs or urethral injury, previous urethral or prostate surgery
Watchful waiting rationale
A number of patients with LUTS suggestive of BPH are affected by an indolent, nonprogressive disease that does not require active treatment.
WW patients should be followed up every ___ to detect progression/complications.
Every year/yearly
WW Fluid management (4)
Daily fluid intake 1500-2000 m
Avoid inadequate/excessive fluid intake based on FVC
Fluid restriction when symptoms are inconvenient
Fluid restriction in the evening for nocturia (2 hours before sleep)
WW Caffeine and alcohol self-management (3)
Avoid caffeine
Avoid alcohol in the evening if nocturia is bothersome
Small-volume alcoholic drinks (wines and spirits, vs. beer)
WW Toileting and Bladder Retraining
Advise double-voiding (extra time on toilet to empty bladder completely) Urethral milking for dribbling Bladder retraining (increase minimum time between voids to 3 hours, min voided volume 200-400 mL) Avoid constipation
Treatment for:
Male LUTS (no indications for surgery)
No bothersome symptoms
WW
Treatment for:
Male LUTS (no indications for surgery)
Bothersome symptoms
Predominant
Education
Lifestyle advice
+/- vasopressin analogue
Treatment for:
Male LUTS (no indications for surgery)
Bothersome symptoms
Storage symptoms predominant
Education + lifestyle advice with or without muscarinic receptor antagonist/beta –3 agonist
Treatment for: Male LUTS (no indications for surgery) Bothersome symptoms Storage symptoms, polyuria and nocturia NOT predominant Prostate > 40 mL, long term
Education + lifestyle advice with or without
5α-reductase inhibitor ± α1- blocker/PDE5l
Treatment for: Male LUTS (no indications for surgery) Bothersome symptoms Storage symptoms, polyuria and nocturia NOT predominant Prostate < 40 mL
Education + lifestyle advice with or without α1-blocker/PDE5l
Treatment for: Male LUTS (no indications for surgery) Bothersome symptoms Storage symptoms, polyuria and nocturia NOT predominant Prostate < 40 mL With residual storage symptoms
Education + lifestyle advice with or without α1-blocker/PDE5l
Add muscarinic receptor antagonist/beta –3 agonist
Patients with successful TWOC: ___% will fail within ___ months
80% will fail to void within 6 months
__ period is considered a reasonable compromise to increase the accuracy of frequency-volume charts without decreasing patient adherence.
. A 3-day period
___ be considered in patients presenting with storage symptoms and a history of smoking to rule out urothelial neoplasms.
URINE CYTOLOGY
The diagnosis of bladder outlet obstruction relies on __.
- a. Invasive urodynamic tests.
t/f Among adrenergic receptors, the β-1 subfamily is poorly represented in the lower urinary tract and is not targeted by any of the currently available treatments for LUTSs.
true
Uroselective agents have high affinity for the __ and __ receptors; as such, they have greater selectivity for prostatic and urethral tissue.
a-1, a-1d
. As a consequence of the vascular side effects associated with the inhibition of α-1b receptors,__is frequently reported after treatment with terazosin and doxazosin. 1
dizziness
Randomized trials assessing treatment with dutasteride and finasteride have shown a prostate volume reduction ranging from __ after __ months of treatment.
Ss
15% to 30%
6-24 months
Patients should be warned regarding a higher risk of __ associated with 5-ARI treatment.
depressive symptoms
___ monotherapy has been shown to significantly decrease the IPSS score as compared with placebo. Several randomized trials demonstrated significant relief Conversely, there is no evidence of improved __ parameters with PDE5is alone.
pDE5i
no improvement of urinary flow
__ TRIAL demonstrated that combination therapy of an α-blocker and a 5-ARI can significantly reduce the risk of disease progression at long-term follow-up. This effect was greater than with both placebo and monotherapy
The MTOPS trial
The CombAT study showed a ___ in the risk of surgical treatment for patients treated with dutasteride as compared with tamsulosin.
greater reduction
The PSA test should be considered for patients with a life expectancy longer than __
10 years.
should be considered if bladder motility alterations (e.g., detrusor overactivity, detrusor underactivity) are suspected
- Invasive urodynamic tests
__ are effective in relieving LUTSs, either alone or in combination with α1-blockers.
PDE5is
phytotherapy in LUTS
s, repens
The use of __ is recommended to increase the odds of a successful TWOC.
a1-blockers
. Dutasteride and finasteride have been shown to significantly decrease the risk of __ ` in patients with moderate to severe LUT
AUR
In the course of performing a monopolar TURP under spinal block, the nurse anesthetist reports the patient is suddenly markedly confused, brachycardic, and hypertensive. Patient is likely experiencing TUR syndrome; thus rapid termination is needed. The height of the irrigating fluid above the patient should be carefully chosen. Investigators have demonstrated that the ideal height of the fluid was ___ above the patient. This appears to be the minimal height to maintain good vision but also not lead to excessive systemic fluid absorption. Increasing the height ___ above this leads to increased pressure in the prostatic fossa and a greater than twofold increase in systemic fluid absorption. Diagnosis of this condition is made by assessment of neurologic status and comparison to laboratory values. Serum sodium should be obtained in long, large resections postoperatively (or intraoperatively if concern exists). A serum sodium of ___ indicates a significant dilution and may lead to coma or seizures. Transient visual disturbances or blindness indicate central nervous system (CNS) toxicity and are obviously very distressing to all the parties involved. If profound central nervous symptoms are noted, judicious administration of ___ should be instituted and formulas exist to help guide this resuscitation as overly rapid correction of hyponatremia may lead to a___
60 cm
10 cm
less than 120 mEq/L
Hypertonic saline
demyelinating lesion of the brain (central pontine myelinolysis).
risk factors for TUR syndrome: Failure to use ___, ___ irrigating solution and the bipolar electroresection system
steps to prevent TUR syndrome:
the use of isotonic, iso-osmolar irrigating solution and the bipolar electroresection system this risk has theoretically been eliminated.
While most authors agree that TUR syndrome is caused by dilutional hyponatremia, there have been alternate etiologies proposed. Excessive glycine absorption can lead to liberation of __ from metabolic pathways leading to immediate or delayed encephalopathic symptoms. Several steps can be taken to prevent this complication. Use of a __ resection method should certainly be considered. The __of the irrigating fluid above the patient should be carefully chosen. Use the ___ to maintain good vision but also not lead to excessive systemic fluid absorption.
risk: Failure to use isotonic, iso-osmolar irrigating solution and the bipolar electroresection system.
ammonia
bipolar
height
minimal height
ETIOLOGY OF TUR SYNDROME: Absorption of non–___-containing irrigating fluid, leading to an acute __. Absorption of non– sodium-containing irrigating fluid into the __ that is exposed during resection is the etiology of the disease. This risk appears to be unique to __; other BPH techniques (such as bipolar TURP, HoLEP, and laser vaporization) use isotonic/iso-osmolar irrigating fluid such as normal saline. The ideal height of irrigating fluid was determined to be __ cm above the patient, as this balanced the benefits of visualization with systemic absorption. Heights above this level will lead to an increased systemic absorption. In general, symptoms of TUR syndrome begin with a serum sodium of ___
non- sodium
dilutional hyponatremia
prostatic venous system
Monopolar turp
60 cm above the patient
less than 120 mEq/L.
TRUE regarding transurethral incision of the prostate (TUIP)
It may have a ___ of ejaculatory dysfunction in patients when done unilaterally. The procedure is relatively short and does not cause __. The procedure is only appropriate for small prostate glands (generally __), and no prostate adenoma is removed. ___ occurs in up to 37% of patients. Although this is controversial, most authors believe that the risk of retrograde ejaculation is lower if done __ as opposed to bilaterally
lower rate
TUR SYNDROME
less than 30 ml
RETROGRADE EJACULATION
unilaterally
